Case contributed by Naim Qaqish
Diagnosis certain


End-stage renal disease for permcath insertion.

Patient Data

Age: 50 years
Gender: Male



There are three oval shape hypoechoic lesions related to right upper and both lower parathyroid glands suggesting three parathyroid adenomas.

They measure 1.5 cm (right upper), 1 cm (right lower), and 1.3 cm (left lower).

The thyroid gland is normal in size, echogenicity and echotexture. No nodules or cysts are detected.

No any significant cervical adenopathy.



Cardiomegaly with congested central vessels more in cephalic orientation indicating edema.

Left middle zone atelectasis is seen.

Deformed and lucent lateral aspects of the clavicles with widening of the acromio-clavilcular joints. Superior and inferior rib notching is also noticeable bilaterally due to secondary hyperparathyroidism.

Central venous line is seen with its tip in the region of the superior vena cava with no evidence of pneumothorax.

Skull and both wrists


Large soft tissue calcifications are seen around both wrist joints and in the left distal forearm  with overlying soft tissue bulging.

The visualized bones demonstrate diffuse osteopenia.

Osteolysis of the distal phalanges involving the right thumb and right little finger.

Heavy arterial calcifications are also seen.

The skull vault, show diffuse thickening with multiple small lytic lesions possibly due to hyperparathyroidism, less likely multiple myeloma.

Findings are due to hyperparathyroidism.

Case Discussion

This 50 year old gentleman is known to have chronic renal failure, was admitted to our hospital for permcath insertion to undergo dialysis. Initially his physician in charge requested thyroid ultrasound which showed hyperplastic parathyroid glands due to his condition of long standing hypocalcemia. Chest x-ray was done after permcath insertion, and demonstrated subchondral resorption of the lateral  clavicles with no evidence of pneumothorax. X-ray of the skull and both wrists were also done depicting multiple tiny lucent skull vault lesions, soft tissue calcifications, bone demineralization, rib notching and acro-osteolysis all these findings due to secondary hyperparathyroidism.

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